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Purpose:To propose a classification for the progressive phases establishing retinal-choroidal anastomosis (RCA), using confocal scanning laser ophthalmoscopy (cSLO) angiography and corresponding (eye-tracked) spectral-domain optical coherence tomography (SD-OCT). Methods:We retrospectively evaluated the angiographic and corresponding tomographic features for all consecutive eyes with RCA, who underwent HRA (Heidelberg Retina Angiograph)+Spectralis SD-OCT over a 18-month period. Results:Thirty eyes of 27 patients were included for analysis. In 7 / 8 eyes showing a focal staining on cSLO angiography, the corresponding SD-OCT scan showed a focal retinal pigment epithelium (RPE) erosion ("erosion sign") over a small, localized RPE elevation. In 9 / 10 eyes showing a typical "hot spot" in the late cSLO angiographic frames, and absence of a serosanguineous pigment epithelium detachment (PED), the corresponding SD-OCT scan showed a focal RPE break leaving 2 free RPE flaps ("flap sign") at the level of a small, localized RPE elevation. In 11 / 12 eyes showing a typical "hot spot" in the late cSLO angiographic frames, and presence of a serosanguineous PED, the corresponding (eye-tracked) SD-OCT scan showed, at the level of a large serosanguineous RPE detachment, a focal funnel-shaped RPE joining an inverted focal funnel-shaped inner neuroepithelium ("kissing sign"). Presence of the typical "hot spot" in the late angiographic frames, in eyes showing a serosanguineous PED, as well as the "kissing sign" on SD-OCT, were significantly associated with presence of the intraretinal hemorrhages, SRF and CME (p

Purpose To study the functional results of macular surgery and determine pre-operative features associated with better final visual outcome. Methods Forty-two consecutive patients underwent surgical removal of subfoveal choroidal neovascularization (CNV), related to age-related macular degeneration (AMD) in 8 eyes, degenerative myopia in 14 eyes, multifocal choroiditis (MFC) in 10 eyes, idiopathic CNV in 6 eyes and other etiologies in 4 eyes. Mean age was 49 years. Pre-operative visual acuity (VA) was 20/200 or less in 30 eyes (71.4%) and never better than 20/40. Fluorescein angiography was analyzed before and after surgery. Pre-operative optical coherence tomographs (OCT) were studied in a masked fashion. Mean follow-up was 12 months (range 4–48 months). Results Final VA was 20/200 or less in 25 eyes (60%). According to the CNV etiology, the percentage were 87.5%, 80%, 57.1% and 20% respectively in eyes with AMD, MFC, high myopia, and idiopathic or other diseases. Post-operative VA improved in 21 eyes (50%) but subsequently declined in 7% by the final examination. Patients younger than 50 years had better functional results (p=0.006). Lack of retinal pigment epithelium (RPE) changes on pre-operative angiography was correlated with good visual outcome (pConclusions CNV surgical excision results vary depending on the underlying disease, the RPE and choriocapillaris function, and the features observed on pre-operative OCT images.

Objectif : Analyser les effets d’une supplémentation en DHA (acide docosahexae- noïque) chez des patients atteints de forme tardive de maladie de Stargardt. Matériels et Méthodes : Douze patients non apparentés (4 femmes, 8 hommes) avec une moyenne d’âge de 46 ans (24-72) ont été inclus. Du DHA sous forme de triglycérides à la dose de 840 mg/j a été donné aux 12 patients durant 6 mois. Tous les patients ont bénéficié d’un examen ophtalmologique complet incluant mesure de l’acuité visuelle, clichés couleurs du fond d’œil, clichés en autofluorescence, angio- graphie à la fluorescéine, ICG, OCT et ERG multifocal à l’inclusion et au 6e mois. Résultats : Deux sur les 12 patients ont eu une nette amélioration de l’acuité visuelle et des données de l’ERG multifocal. Pour le premier, le pic d’amplitude de l’onde a est passé de 66 à 75,4 OD et 24,5 à 49,1 OG. Le pic d’amplitude de l’onde b est passé de 122 à 157 OD, et 102 à 149 OG. Pour le second, seul l’œil droit a été inclusdans l’étude en raison de néovaisseaux choroïdiens à l’œil gauche. Les pics d’ampli- tudes des ondes a et b ont respectivement augmenté de 11,8 à 72,1 et de 53 à 185. Discussion : Un effet bénéfique du DHA a pu être mis en évidence chez 2/12 patients. L’analyse des gènes ABCA4 et ELOVL4 est en cours afin d’essayer d’établir des facteurs prédictifs d’efficacité du traitement par DHA. Conclusion : Cette étude supporte l’hypothèse d’un effet bénéfique du DHA chez certains patients atteints de maladie de Stargardt.

PURPOSE: To determine if photodynamic therapy with verteporfin (Visudyne; Novartis AG, Bulach, Switzerland), termed verteporfin therapy, can safely reduce the risk of vision loss compared with a placebo (with sham treatment) in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration who were identified with a lesion composed of occult with no classic choroidal neovascularization, or with presumed early onset classic choroidal neovascularization with good visual acuity letter score, METHODS: This was a double-masked, placebo controlled (sham treatment), randomized, multicenter clinical trial involving 28 ophthalmology practices in Europe and North America. The study population was patients with age related macular degeneration, with subfoveal choroidal neovascularization lesions measuring no greater than 5400 mum in greatest linear dimension with either 1) occult with no classic choroidal neovascularization, best-corrected visual acuity score of at least 50 (Snellen equivalent approximately 20/100), and evidence of hemorrhage or recent disease progression; or 2) evidence of classic choroidal neovascularization with a best-corrected visual acuity score of at least 70 (better than a Snellen equivalent of approximately 20/40); assigned randomly (2:1) to verteporfin therapy or placebo therapy. Verteporfin (6 mg per square meter of body surface area) or placebo (5% dextrose in water) was administered by means of intravenous infusion of 30 mi over 10 minutes. Fifteen minutes after the start of the infusion, a laser light at 689 nm delivered 50 J/cm(2) by application of an intensity of 600 mW/cm(2) over 83 seconds using a spot size with a diameter 1000 mum larger than the greatest linear dimension of the choroidal neovascularization lesion on the retina. At follow-up examinations every 3 months, retreatment with the same regimen was applied if angiography showed fluorescein leakage. The main outcome measure was at least moderate vision loss, that is, a loss of at least 15 letters (approximately 3 lines), adhering to an intent-to treat analysis with the last observation carried forward to impute for missing data. RESULTS: Two hundred ten (93%) and 193 (86%) of the 225 patients in the verteporfin group compared with 104 (91%) and 99 (87%) of the 114 patients in the placebo group completed the month 12 and 24 examinations, respectively. On average, verteporfin-treated patients received five treatments over the 24 months of follow-up. The primary outcome was similar for the verteporfin-treated and the placebo-treated eyes through the month 12 examination, although a number of secondary visual and angiographic outcomes significantly favored the verteporfin-treated group. Between the month 12 and 24 examinations, the treatment benefit grew so that by the month 24 examination, the vertepor-fin-treated eyes were less likely to have moderate or severe vision loss. Of the 225 verteporfin-treated patients, 121 (54%) compared with 76 (67%) of 114 placebo-treated patients lost at least 15 letters (P =.023). Likewise, 61 of the verteporfin-treated patients (30%) compared with 54 of the placebo-treated patients (47%) lost at least 30 letters (P = .001). Statistically significant results favoring verteporfin therapy at the month 24 examination were consistent between the total population and the subgroup of patients with a baseline lesion composition identified as occult choroidal neovascularization with no classic choroidal neovascularization, This subgroup included 166 of the 225 verteporfin-treated patients (74%) and 92 of the 114 placebo-treated patients (81%). In these patients, 91 of the verteporfin-treated group (55%) compared with 63 of the placebo-treated group (68%) lost at least 15 letters (P =.032), whereas 48 of the verteporfin-treated group (29%) and 43 of the placebo-treated group (47%) lost at least 30 letters (P =.004). Other secondary outcomes, including visual acuity letter score worse than 34 (approximate Snellen equivalent of 20/200 or worse), mean change in visual acuity letter score, development of classic choroidal neovascularization, progression of classic choroidal neovascularization and size of lesion, favored the verteporfin-treated group at both the month 12 and month 24 examination for both the entire study group and the subgroup of cases with occult with no classic choroidal neovascularization at baseline. Subgroup analyses of lesions composed of occult with no classic choroidal neovascularization at baseline suggested that the treatment benefit was greater for patients with either smaller lesions (4 disc areas or less) or lower levels of visual acuity (letter score less than 65, an approximate Snellen equivalent of 20/50(-1) or worse) at baseline. Prospectively planned multivariable analyses confirmed that these two baseline variables affected the magnitude of treatment benefit. Of the 123 verteporfin-treated patients and 64 placebo-heated patients with either visual acuity score Less than 65 or lesion size 4 disc areas or less at baseline, 60 (49%) and 48 (75%) lost at least 15 letters (P < .001), respectively, and 26 (21%) and 31 (48%) lost at least 30 letters (P 2001 by Elsevier Science Inc. All rights reserved.).

To assess the effects of pegaptanib in the treatment of subfoveal occult choroidal neovascularisation (CNV) associated with neovascular age-related macular degeneration (NV-AMD) in a compassionate use program in France. Pegaptanib was authorized for patients with CNV-associated visual impairment and in whom usual care (thermal laser photocoagulation or photodynamic therapy with verteporfin) was not appropriate. Patients with occult CNV lesions received intravitreous pegaptanib (0.3 mg every 6 weeks) and were followed with repeated fluorescein angiography, scanning laser ophthalmoscopy-infracyanine green angiography, and ocular coherence tomography through 52 weeks. Of 56 patients (predominantly occult, N=22; purely occult, N=8; occult with chorioretinal anastomosis, N=12; occult with pigment epithelial detachment, N=14), 30% had earlier treatment. All received eight pegaptanib injections. At week 52, 79% were responders (lost

Previous studies have reported that an elevated plasma homocysteine level is a risk factor for vascular disease. The aim of this study is to determine whether hyperhomocysteinemia is a risk factor for retinal vein occlusion (RVO) and whether it is a prognostic factor.The plasma homocysteine level was measured in 101 patients and compared to the plasma homocysteine level of controls. The relation between plasma homocysteine level and the other known risk factors of retinal vein occlusion was studied, as well as the correlation between the clinical outcome of the RVO and the plasma homocysteine level.The mean plasma homocysteine level was significantly higher in the 101 RVO patients than in the 29 controls (11.9 mmol/l vs 8.6, p0.001). We found no relation between plasma homocysteine and other risk factors of vascular disease except for the hematocrit level. Hyperhomocysteinemia was more frequent in the ischemic forms and in bilateral RVO, but the difference was not statistically significant.Hyperhomocysteinemia seems to be an independent risk factor for RVO and was more frequent in severe RVO, but our study did not evidence an association with a severe prognosis. Vitamin therapy can decrease homocysteinemia but its efficacy in the prevention and in the treatment of RVO remains to be demonstrated.

PURPOSE. To evaluate quantitatively the effect of grid laser photocoagulation in macular edema due to central and branch retinal vein occlusion, using the retinal thickness analyzer. METHODS. Five patients with cystoid and non-cystoid macular edema were studied before and after argon grid laser treatment. All were examined clinically, with fluorescein angiography, and measurement of retinal thickness. Macular thickness was correlated to visual acuity measured on the ETDRS chart. RESULTS. Laser-slit images obtained with the retinal thickness analyzer in patients with macular edema disclosed discrete intraretinal changes after photocoagulation. Biomicroscopy and fluorescein angiography were insensitive to these small changes in the retinal thickness. No patient had any change in visual acuity after three months, but the retinal thickness was greater at this interval. The retinal thickening may be explained by a postoperative inflammatory response or by altered retinal blood flow or, in two of the eyes, by the effect of combined peripheral photocoagulation. CONCLUSIONS. The retinal thickness analyzer offers a refined tool for the diagnosis of subclinical changes of macular edema in retinal vein occlusion and is therefore also useful for assessing the effects of treatment.

We report the case of a 39-year old man who presented with central serous chorioretinopathy. Two months after diagnosis, argon laser photocoagulation was performed. One month later, the patient noticed distortion and a reduction in vision revealing a subretinal neovascularization above the fovea next to the laser scar. The patient underwent surgical extraction of the neovascular membrane and recovered a visual acuity of 20/30. This case report shows a complication of laser treatment of central serous chorioretinopathy and underlines the diagnostic difficulties of this disease and its treatment modalities. The surgical excision, the first reported in this etiology, led to good visual recovery, as is usually observed in young patients operated on for neovascular membrane.

Subfoveal choroidal neovascularization is a main cause of blindness. The new surgical technique of macular translocation conceived by De Juan, with scleral shortening and without a retinotomy, allows to move the fovea away from the neovascular membrane with a low rate of complications. The first results obtained with this technique are presented here, in cases of submacular neovascularization due to age-related macular degeneration (AMD) or degenerative myopia.The first 10 patients who were operated on with this technique presented with subfoveal neovascularization due to AMD (6 eyes) or myopia (4 eyes). The time period between the beginning of the disease and surgery was less than 3 months. Before and after surgery, a complete examination included fluorescein and ICG angiographies and OCT.Visual acuity improved by 2 lines or more in 6 eyes (60%), was unchanged in 3 eyes (30%) and decreased in 1 eye. The improvement in vision seemed higher in myopia than in ARMD. Conversely, the mean foveal displacement was greater in ARMD than in myopia (1.2 disc diameter and 0.5 respectively). Laser photocoagulation has been performed in all patients after surgery. Main complications were retinal detachment (1 eye) and neovascularization at the site of transretinal injection (1 eye). Mean follow-up was 3 months.Macular translocation with the technique described by De Juan allowed visual improvement in more than the half of the eyes with subfoveal neovascularization, resulting in a moderate rate of complications. Long term follow-up is necessary to confirm these results.

Retinal detachment after Nd: YAG laser vitreolysis is rarely reported. The pathogenic role of Nd: YAG laser is analyzed from 3 cases of severe retinal detachment.Three men aged (40 to 59 years old) had one or more risk factors for retinal detachment: myopia, complicated cataract surgery, personal or family history of retinal detachment. Nd: YAG laser treatment onto vitreous strand was performed because of: retinal traction, repeated vitreous hemorrhage, anterior vitreous strand in a aphakic patient with cystoid macular edema. Within six weeks following Nd: YAG laser vitreolysis, severe retinal detachment with several tears occurred, complicated with proliferative vitreoretinopathy in two patients, and with choroidal hemorrhage in one. In two cases, several surgical procedures with silicon oil were required and visual acuity remained under 20/1000. In the last case retinal reattachment was obtained with scleral buckling and cryopexy, the patient recovered a visual acuity of 20/100 with a macular pucker.Retinal detachment occurred shortly after laser YAG vitreolysis. We assumed Nd: YAG laser was possibly responsible and investigated the possible mechanisms: direct retinal tear, vitreous strand traction, side effect of intraocular shock wave.Nd: YAG laser vitreolysis seems to be able to cause retinal detachment. Its use is therefore not recommended, particularly in patients at risk, especially since the efficacy of this treatment has not been proved.

Optic nerve pit is a rare congenital anomaly. In two third of the patients, the severity of the disease is increased by the apparition of a serous macular detachment, which may compromise the visual prognosis. The aim of this study is to propose a therapy appropriate to such complication.A prospective study was performed including 10 patients with a serous macular detachment caused by optic nerve pit. All patients underwent intraocular surgery including vitrectomy, peripapillary photocoagulation and intravitreal injection of gas. The mean postoperative follow-up period was 9.5 months.Therapy success was based on anatomical and functional results. Serous macular detachment reattached in 7 patients out of 10 and a recurrence was observed in one case. Visual acuity improved from 0 to 18 lines of the EDTRS chart (mean increase: 6.7 lines).These results confirm that intraocular surgery including vitrectomy-photocoagulation-gas injection is a valuable treatment for serous macular detachment associated with optic nerve pit.

Exudative age-related macular degeneration (ARMD) is now benefitting from new therapeutic approaches. Three international randomized clinical trials have demonstrated the efficacy of photodynamic therapy (PDT) in stabilizing visual acuity at 2 years. PDT is based on the activation of a photosensitizer with an adapted wavelength. In age-related macular degeneration, the photosensitizer used is verteporfin (Visudyne), which accumulates preferentially in choroidal new vessels. Functional results are obtained on the basis of a strict classification based on fluorescein angiography examining the type of the new vessels responsible for exudative ARMD. Thus, subfoveal lesions, either predominantly classic (>50%) or occult only, are the indication for PDT. Classic CNVs where laser photocoagulation thermal burns extend into the foveola may be an extrapolation of the indication for PDT. In addition, fluorescein angiography is essential for considering retreatment, usually necessary. Demonstrated growth and the persistence of leakage from the CNV is an absolute indication for a new session of PDT. A number of features still require assessment in order to define the responder group more accurately and to refine and possibly simplify the indications for retreatment.

A case of central retinal vein occlusion with second development of the same type of retinal vein occlusion in the fellow eye, is reported. The patient was a 68 year-old man with a history of thyroid gland disorder and a cardiac arrhythmia. He presented also with bilateral tilted disc. The first eye occlusion was initially nonischemic, but converted secondarily into an ischemic type and required laser panretinal photocoagulation. The biological assay found the presence of lupus anticoagulant antibodies and rheological findings (major plasma hyperviscosity, increased erythrocyte aggregation, high hematocrit and fibrinogen levels). The patient was given high doses of troxerutin, and aspirin. Central retinal vein occlusion occurred in the fellow eye one year later, a few weeks after the decrease of troxerutin doses. Hemodilution therapy was performed and visual acuity remained unchanged. Unusual risk factors for retinal vein occlusion are discussed. Lupus anticoagulant antibodies may sometimes lead to occlusive vascular phenomenon. Although these antibodies are not commonly found in retinal vascular occlusion, they may constitute a contributory factor. Tilted disc has often been involved in the pathogenesis of central retinal vein occlusion. Finally, abnormal rheological findings, major in this case, are found in more than half of the cases of retinal vein occlusion.

Nd:YAG capsulotomy is currently performed after extracapsular cataract surgery and seems to increase the risk of postoperative retinal detachment. In order to evaluate the incidence of this complication in our experience, we retrospectively studied 144 patients who underwent Nd:YAG laser posterior capsulotomy with at least a six-month follow-up. Six patients out of 144 (4.16%) subsequently developed rhegmatogenous retinal detachment. The average time from extracapsular cataract surgery to YAG capsulotomy was 21 months (11 to 26 months). The average time from capsulotomy to retinal detachment was 3.6 months (1 to 8 months). In 4 out of 6 eyes, at least one risk factor for retinal detachment was present (myopia, lattice degeneration, retinal detachment in the fellow eye). Vitreous cells were observed in 4 patients after capsulotomy. In 2 patients, a prophylactic laser photocoagulation had been previously performed. These retinal detachments were not different from aphakic or pseudophakic detachment, but the examination of retinal periphery was particularly difficult because of the peripheral capsular fibrosis, hiding retinal tears in 4 eyes. Two cases of moderate proliferative vitreoretinopathy were observed. Retinal reattachment surgery was successful in all cases with one procedure. The YAG laser energy required to create a capsulotomy was less than that reported in the literature, and no relationship could be established with the total energy applied. Nd:YAG capsulotomy seems to moderately increase the risk of retinal detachment, especially in myopic patients. The mechanisms of vitreous and retinal damage after Nd:YAG capsulotomy are discussed.